To answer this question, we need to understand what determines health and to focus on the social determinants. There are of course biological determinants, for example familial hyperlipidaemia which may have genetic antecedents, however to discuss biology is to make the original question redundant. To move on to personal responsibility for health I take the position of the ‘social determinants of health’ approach which argues:
“The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries” : http://www.who.int/social_determinants/en/
Inherent in that description is the idea that the society in which you grow up ‘acts’ upon you and thus determines your health. Emile Durkhiem (1895) wrote about what we might think of as ‘social forces’ acting upon us; the sociologist, he suggested, is to ‘treat social facts as things’ which are
“a category of facts which present very special characteristics: they consist of manners of acting, thinking, and feeling external to the individual, which are invested with a coercive power by virtue of which they exercise control over him” (p52).
Note the use of the word coercive power, which suggests that society coerces us into a particular manner of thoughts, feelings and behaviours. We are, in this view, crudely determined by the society we grow up in. It is fair to say that social theory has moved on from crude determinism.
What however is still being discussed is the degree to which we exercise our own ‘agency’; our ability to act upon our own autonomous thinking, feeling, manners, customs and norms as free ‘agents’. To that we also consider the degree to which social ‘structures’, family, schools, occupations, socio-economic status, gender and ethnicity, act upon us and constrain social and individual action. This sets up the agency-structure dichotomy. Many sociologists tend to emphasise social structure as guiding behaviour while historians emphasise agency in human affairs. We need to come to an understanding that gets away from crude models of the either/or of structure or agency.
To take the position that we are 100% responsible for one’s health status requires the ability to make choices free from external constraints…to act and behave in a manner that enhances our health status unencumbered by external forces, such as lack of clean water or the advertising and availability of certain products, that would ‘act’ upon us. We must, in this view, be free agents, indeed in this view, we are free agents, able to make autonomous decisions. It also requires us to be able to be critically self reflective of internal thought processes (our ‘inner conversations’) and subconscious desires that lead us into unhealthy behaviours. Not only must we be critically self reflective so that we come to understand our inner motives but we must also be able to act upon that knowledge. When we reach for a bottle of sugared water in a supermarket which is packaged to appeal to a particular lifestyle, but which has no health benefit whatsoever and indeed is linked to dental caries if consumed in place of plain old water, we do so in the full knowledge of its health effects and we do so as uncoerced free agents. To be 100% responsible we need to be 100% free agents of our destinies. This is the agency end of the argument.
On the other hand we note that social inequalities are linked to distinct patterns of mortality and morbidity that often follows socio-economic status. These patterns are what we call ‘health inequalities’, and so we come to think that society is working upon us to create patterns of health and illness. This is the crude ‘structure’ approach, which draws from material deprivation theories of ill health. It is if being of a lower social class acts upon us as a social force. Danny Dorling (2013) certainly suggests that health and social inequalities are not two separate entities but ought to be seen as one phenomenon, that is not to say however that Dorling adheres to structural determinism.
Graham Scambler (2013) asks us to consider ‘agency’ as well in a more nuanced understanding of our responsibility for health and to do this he refers to the work of Margaret Archer and the idea of ‘inner conversations’.
“Humans…are simultaneously the products of biological, psychological and social mechanisms while retaining their agency…socially structured without being structurally determined” (p147).
Who, and what, we are arises socially, as well as from our physical biological selves and as well as from our psychological thinking and motivations. Society structures who we are without determining who we are. Your family life structures you – it gave you language, culture, hopes and aspirations but does not determine these aspects of your self. There is room for agency.
We need to consider how our ‘inner conversations’ shape our responses to how we see and feel the way external social structures such as our families, and cultural powers, such as occupational positions or the food industry, act upon us. These responses then result in our social behaviours and values. That is why similar social structures produce similar patterns of behaviour but does not determine them. As an example, take dialect and accent. Social structures ‘determine’ whether you will grow up speaking with a particular accent but does not make it fixed. A child does not actively choose to speak certain words in a certain way, but as with many in their peer group, it almost looks as if they were determined to do so. The same goes with later health choices.
Added to that is the structure of opportunities a society provides children with. In a social world where cigarettes are seen to be the norm, and also are imbued with notions of adulthood, it is not surprising that many children ‘choose’ to smoke. Agency however means that some children are free not to smoke and choose not to. Some will cite trying it and being put off by taste, but not all. Their ‘inner conversation’ tells them to get past that barrier. The social structure of norms and expectation around smoking is tempered by agency, the freedom not to act in this case. So why and
how do we exercise agency in social circumstances? This is a question to return to below, first another example.
In ‘Oranges are not the only fruit’ – a coming of age novel, Jeanette Winterson describes how growing up a lesbian in a strict religious family acted upon her choices and feelings without determining the outcome, she did not grow up to be a member of her family’s Pentecostal church and to renounce her sexuality. Her ‘inner conversation’ resulted in a rejection of the strict religious lifestyle and belief system. In her case her behaviours and values were socially structured but not determined. Of course in many other families children do acquire the religion of their parents, their inner conversations lead them in what looks like a deterministic way.
So we need to see that agency works within a context, e.g. a religious family, in which the social outcome is structured by that family but not determined by it. How does happen? Lets consider the structure of family.
- The family provides the external, objective, situation and context which the free agent is then confronted with. The agent does not have a choice about this. The family provides situations of constraint and opportunities for the ‘agent’. Lets change that term ’agent’ for ‘child’. This objective situation operates in relation to…
- …the child who has their own internal, subjective, concerns in relation to physical nature, social realities and cultural practices. In Winterson’s case this subjective concern involved her awaking sexuality which ran counter to the family’s religious teaching. Her inner conversations told her something, and of course this is where biology might intervene.
- The action undertaken by Winterson was partly produced by her ‘reflexive deliberations’, i.e. her internal thinking about the situation and her own concerns. Children determine their choices of practical action in relation to their objective circumstances. Some choices will require quite deep reflexive thinking and commitment, especially if the inner conversation is saying something like “I feel sexual attraction to girls” in the face of objective situations, i.e. the family, which says “same sex attraction is sinful’.
In Wintersons’ case her agency trumped social structure.
Let’s consider a health example using the same steps:
- The family buys mainly processed foods from supermarkets, they do not use local organic farmer’s markets as they are viewed as expensive and require a drive that is further away. In addition the parents buy sugared water as it is cheap and not seen as unhealthy. This is the objective context that structures the child’s responses.
- The child’s own inner subjective concerns do not entail a detailed analysis of the food production, manufacturing, distribution and marketing process. The child experiences tasty, often sweet and satisfyingly available foods. The inner conversation says “I like this” and takes note of what peers and family say and do.
- The child’s action does not involve a rejection of the food choices but actively embraces them. In this case the inner reflexive deliberations do not run counter to either family values or social values and requires little in the way of critical reflection.
Social structure in this case provides the contexts for agency not to challenge it.
These two very short examples, illustrate the interplay between structure and agency and how behaviour is ‘structured but not determined’. However, one may understand how forceful structures may appear to be in shaping the individual responses. I think this is what is meant by the use of the word ‘social determinants’ in the ‘SD of health’ approach.
So far, this is not so complex to understand. We know that social structures do not determine behaviour otherwise there would not be any social change. However we also recognise the power that certain social ‘forces’ have in reproducing cultural practices such as religious observance or eating habits.
Modes of reflexivity
We need to then consider the interplay between structure and agency and consider why in one case agency ran counter to social pressures, but not only ran counter it overcame them. Is the inner conversation that is driven by sexuality particularly powerful? Scambler’s point regarding the interplay of biology, psychology and social structures is important to remember when considering this.
Margaret Archer (in Scambler 2013) argues that the interplay between our internal concerns and our social and environmental contexts is shaped what she calls a ‘mode of reflexivity’. A ‘mode of reflexivity’ is the manner in which we think about our thinking, our ‘inner conversations’ that then shape our actions. Archer outlines 4 ‘ideal types’ of modes of reflexivity which she drew from empirical studies:
- Communicative reflexivity: our inner conversations require confirmation and communication with others before we act. We all do this but for some people this is the dominant mode and it requires that we must pay attention to what others are thinking and take this into account, and action will be based on what those others are thinking. These others may be peers, family and the local people, hence the tendency to social immobility. A student nurse who is dominated by communicative reflexivity will consider what their peers and mentors are thinking and will want to act in such a way as to fit in. Consensus is sought after.
- Autonomous reflexivity: our inner conservation requires no confirmation with others, they are self sustained and lead directly to action. Here we have a ‘lone inner dialogue’ which then leads to action. If this is dominant then the person will not seek or require the involvement of others. Autonomous reflexives might use communicative reflexivity but it is not strictly necessary. A student nurse thinking in this way will act upon their own deliberations and not always require consultation or considering others’ thinking. Outcome rather than consensus is important. Was Winterson, in relation to her sexuality, exercising autonomous reflexivity?
- Meta reflexivity: our inner conversation is subjected to criticism and we critique whether effective action in society is possible before we act. This is about self monitoring, our thinking about how we think, and when dominant results in self questioning such as ‘why did I say that?’, ‘why am I so reticent to say what I think?’. We may be self critical and concern ourselves with the moral worth of what we do. Values more than consensus or outcome is important. Students nurses are introduced to the idea of critical reflection but it is debatable whether they are skilled at this by the end of a three year programme.
- Fractured reflexivity: our internal conversation intensify the disorientation and distress we already feel and this leads to inaction. Some children, brought up in abusive and neglectful homes, may only develop fractured reflexivity and thus turn in on themselves and withdraw.
This typology delves further into the nature of agency and explains how society and its structures might provide a framework for action but the inner conversation indicate how that structure ‘determines’ action. In the example above we might hypothesis that Winterson was an autonomous reflexive, perhaps driven by nascent sexuality that was so at odds with her family socialisation. It is a moot point to consider that if Winterson was a dominant communicative reflexive, whether her resistance would have been quite so forceful.
The child who eats junk food sitting in front of the TV who is also a communicative reflexive may be ‘determined’ to be obese. Their inner conversation engages with the voices and thinking of their peers who may all be doing the same thing and who consider that this diet is typical and ‘normal’. Children of course may not have developed meta reflexivity, they may not have been taught to do so either by family or school. They may therefore lack critical self reflection. Indeed some child rearing practices may see critical self reflection as self indulgent and not helpful to learning the skills and knowledge needed to make one’s way in the world. Children who are fractured reflexives may be so because of fractured and disorientating childhood experiences and thus be in too fragile a psychological state to consider their own abilities to take action.
The life chances, and thus health choices, that result from choices do so from within people’s social position in which they exercise Autonomous, Communicative, Meta and Fractured reflexivity. Given an abusive childhood, lived in material deprivation, and without the benefit of escape via public school and University education, a child’s life chances are in this sense determined. If that child was an autonomous reflexive early in life they might grow to be to fight against disadvantage, however it might be the case that very early childhood development experiences are linked to certain modes of reflexivity. We don’t know. However, even an autonomous reflexive will struggle against damaging patterns of life they have no option but to choose from.
So to explain why people act differently in similar social situations may be partly down to the inner dominant mode of reflexivity. Their choices however are still structured. A child cannot choose to go to Eton and thus up their chances of becoming Prime Minister. A Duchess does not have to choose between paying a utility bill or buying food for her children. Neither can she ‘choose’ to become a prostitute. Her structure of opportunities however make it far easier to make healthier life choices in terms of diet and exercise but perhaps, not when it comes to eating disorders. A different social structure provides a very different context for those decisions.
We still do not know why a person, however, ‘chooses’ a mode of reflexivity. What makes one child an autonomous reflexive and others communicative? Social structures provide the context in which these modes operate and so offer objectives choices in which to exercise them. As we do not know the relationship between the physical material brain and consciousness it is no surprise that we can’t yet determine in the last instance why people develop a certain cognitive structure of thinking. However, Susan Gerhardt in ‘The Selfish Society’ outlines the importance of early childhood development and the development of empathy which seems to link with communicative reflexivity as it takes account of others thoughts and feelings. Autonomous reflexives may develop out of a different childhood experience.
So, are we 100% responsible for our health? Of course not. Ask a child in Syria right now. The external social world has force, and sometimes that comes armed.
Dorling, D. (2013) Unequal health. Policy Press. University of Bristol
Durkheim, E. (1895) The Rules of Sociological Method. New York. Free Press.
Scambler, G. (2013) Resistance in unjust times: Archer, Structured Agency and the Sociology of Health Inequalities. Sociology. 47 (1): 142-156.